Case Study 4 Orthotics and Orthopedic Shoes – Adult Acquired Flat Foot

By jake | Case Studies

Reason for attending the office: This patient attended for a checkup of an unrelated issue and it was during this first visit that the chiropodist noticed an abnormal left foot position.  After questioning the patient, the foot had been getting gradually flatter and on assessing and pressing the foot (called palpation), the chiropodist was able to determine there was a damaged tendon – something called Posterior Tibial Tendon Dysfunction which had led to weakness and the acquisition of an adulthood flat foot.

Agreed treatment:  The chiropodist arranged an ultrasound scan via the patient’s physician – this confirmed the suspected tendon damage with tearing.  A short-term plan was agreed which included the assessment of gait and biomechanics in order to accurately prescribe both custom orthotics and appropriate orthopedic shoes.  A medium-term plan was implemented with the patient’s physician to include a review with orthopedics so that the possibility of surgical management could be discussed as a medium-to-long term measure.

Alternative Treatment Discussed:  Additional and supplemental treatment is available and included Low Level Laser Therapy, Ultrasound therapy, extracorporeal shockwave therapy or possible cortisone injection therapy to site of maximal tenderness. 

Outcome: Orthotics and orthopedic shoes aim to offload the injured tendon by reducing forces acting on the foot, muscle and tendon.  The photographs and video below show the outcome of an effective foot orthotic and orthopedic shoe on adult acquired flat foot.

Timeframe:  After 5 months, the patient is wearing the orthopedic shoes and running shoes and medium/long term awaits the outcomes of an orthopedic surgical treatment plan.

Conclusion: This is an example how chiropodists are able to pick up on problems, act quickly to help in their assessment, diagnosis and treatment before they have a major impact on the patient’s life or lifestyle.  We aim to help keep patients mobile and active so that they decide for themselves the right time for any future elective orthopedic surgery.

Please note that in most evidence hierarchies current, well designed systematic reviews and meta-analyses are at the top of the hierarchy, with single case studies, expert opinion and anecdotal experience at the bottom. 

Case Study 3 Ingrown Toenail

By jake | Case Studies

Reason for attending the office: This patient attended complaining of a right big toenail that was curling, getting worse over the prior 3-4 years.  There was pain on pressure on the tip of the right big toenail and the pain was exacerbated by the nail curling.  

Agreed treatment:  On assessing this troublesome nail it became apparent that the patient was suffering from an involuted toenail – a type of ingrown toenail where the edges of the nail curve downwards to much.  The patient was already trying to manage the painful curling nail with frequent pedicuresAfter discussing treatment, it was mutually agreed that a nail surgery procedure would the best curative long-term treatment option.  This minimally invasive procedure is carried out in the office under surgical conditions to permanently remove the problem portion(s) of an ingrown toenail.  The aim of this treatment was to remove the problematic curling edges of the toenail, leaving the healthy central nail intact, and to prevent the problematic parts of the nail regrowing.  This procedure suited the patient due to the ease of treatment and minimal discomfort.

Alternative Treatment Discussed:  The option of frequent, professional nail care in our office by a chiropodist to try and minimize recurrent and ongoing pain could be an option.  The patient elected to opt for a more permanent solution rather than committing to a frequent chiropody care visit.

Outcome: Total healing following the procedure was 22 days.

Timeframe: At 4 ½ Months a cosmetic review was undertaken and the result was pleasing and the toenail was looking cosmetically good.

Conclusion: This is an example of how we aim to remedy a painful, deformed, infected or troublesome toenail using common nail surgery procedures and techniques.

Please note that in most evidence hierarchies current, well designed systematic reviews and meta-analyses are at the top of the hierarchy, with single case studies, expert opinion and anecdotal experience at the bottom. 

Study 2 Onychomycosis – Fungal Nail

By jake | Case Studies

Reason for attending the office: This patient attended complaining of a nail that had recently gone ‘funny’ on the right big toe.  Careful assessment revealed a fungal toenail infection.

Agreed treatment: After discussing treatment options which include taking pills, painting on medication and laser surgery for fungal nails, it was mutually agreed that ‘fenestration’ would the best initial treatment option.  A simple procedure is carried out with a sterile medical tool to make tiny little hollows in the fungal nail. The aim of this treatment is to allow a prescribed liquid antifungal to then wick through the hollows and reach the infection.  This procedure suited the patient due to the ease of treatment and minimal discomfort.

Alternative Treatment Discussed:  It was discussed that layered treatment may be needed which could include the use of other modalities such as fungal nail laser surgery and the use of pills.  A layered approach to treatment can help with aims of obtaining some cosmetic improvement and/or a reduction in fungus.


Outcome: At follow up a marked clinical improvement was noted.

Timeframe: The usual timescale for a large toenail to grow from bottom to top is usually about 12 months.  


Conclusion: This is a good example of how treatment can be layered for fungal nail infection.  Whilst this nail responded well to fenestration and topical treatment some infections may require the use of other modalities such as fungal nail laser surgery and / or the use of pills.

Please note that in most evidence hierarchies current, well designed systematic reviews and meta-analyses are at the top of the hierarchy, with single case studies, expert opinion and anecdotal experience at the bottom.

Study 1 Wart

By jake | Case Studies

Reason for attending the office: This patient attended complaining plantar wart that had been on the bottom of the right foot with a secondary cluster under the ball of the foot for some time. It measured the size of a quarter and the patient said it had been present for ‘many, many years!’ The patient had been having a series of treatments every 2-weeks over several months prior to attending and wanted to consider more radical treatment.

Agreed treatment: After discussing options including surgical and non-surgical interventions it was mutually agreed that ‘needling’ would the best initial treatment option. A needling procedure is carried out under sterile surgical conditions painlessly whilst numb under local anaesthetic. The aim of this treatment is to trigger the bodies own immune response – boosting the patients own body to fight off the infecting wart virus infection. This procedure suited the patient as there are generally rapid recovery times, minimal discomfort and prior treatment had failed to impact the condition.

Alternative Treatment Discussed: It was discussed that further treatment may be needed which could include the use of other surgical modalities such as laser surgery and the use of acids or caustics amongst others.

Outcome: Following needling other treatment modalities were then utilised to achieve a complete resolution for this patient including the use of special chemical compounds applied directly to the wart, Laser Surgery and a prescription of a topical cream to boost the immune response.

Timeframe: 18 months to resolution

Conclusion: This is a good example of an ‘intractable’ plantar wart infection which unlike typical plantar wart infections, does not respond quickly to typical treatments. An 18-month timeframe was not unrealistic in the management of this case.

Please note that in most evidence hierarchies current, well designed systematic reviews and meta-analyses are at the top of the hierarchy, with single case studies, expert opinion and anecdotal experience at the bottom.